Debra L. Ness President, National Partnership for Women & Families

1. Disclosure Briefing Overview: Medicare Improvements for Patients and Providers Act of (“MIPPA”) 2008 Debra L. Ness President, National Partnership for Women & Families Co-Chair, Consumer-Purchaser Disclosure Project September 4, 2008

2. Briefing Agenda • Introduction and Context: Debra L. Ness, National Partnership for Women & Families • MIPPA Legislative Background and Value-Enhancing Elements: Billy Wynne, Health Policy Counsel, Senate Finance Committee • Participant Discussion

3. What is MIPPA? • Provides an 18-month “fix” to Medicare physician payments (putting off scheduled 10.6% reduction) • Funds the payment changes largely through reductions in Medicare Advantage Private Fee-for-Service • Includes range of changes to Medicare AND enacts an array of value-promoting elements • MIPPA Legislation

4. Why MIPPA Matters! • Provides a “Roadmap for Reform” by providing concrete support for core value enhancing elements: • Measurement based national standards • Payment changes to reward performance • Support technologies that save lives and money • Many of the value enhancing elements would have seemed pipedreams five years ago • NONE of the value enhancing elements would be there without the concerted advocacy, communication and support of a wide array of consumer, labor and employer organizations that have worked closely with some leading providers to focus legislators attention on the need to create a health care system that measures and rewards higher performance. • Demonstrates broad bipartisan consensus around reforms to promote value (disagreement and veto were about how to pay for the SGR “fix” NOT the value elements)

5. MIPPA Near-Term Impacts on Medicare Beneficiaries • Scope of “beneficiary provisions” • Phases down Medicare's coinsurance for outpatient mental health services to 20 percent over a five year period, beginning in 2010. • Will provide coverage of new preventive services as deemed necessary by HHS, not Congress • Raises the asset test “ceiling” for state Medicare Savings Programs (MSP), and will aggressively promote outreach and enrollment into MSPs • SSA employees will be trained to provide extensive information and assistance to beneficiaries on how to apply for Low-income Subsidy program (LIS), State Health Insurance Counseling and Assistance Programs (SHIPs) and MSPs.

6. MIPPA Advancing Quality Measurement and Public Reporting • Provides core support for the National Quality Forum and the use of nationally endorsed standard performance measures.  • The bill includes $10 million annually from 2009 through 2012 for an organization “like” NQF to help set priorities for health care performance measures and endorse standardized health care performance measures.  • Funding is important and establishes the precedent of recognizing the measurement endorsement process as an important public good.

7. MIPPA builds better performance expectations into Medicare’s plan contracting • Medicare will build on private sector “accountability expectations” for health plans, including: • Requiring new HEDIS reporting requirements for Private Fee for Service (PFFS) plans serving some 2 million members in 2008; • Extending quality reporting requirements for Special Needs Plans (SNPs) • Calling on MedPAC to issue a study comparing the quality of care delivered by Medicare Advantage plans and the traditional fee-for-service program.

8. MIPPA expands the Medicare physician measurement/payment system and requires a roadmap for the future • Measuring individual physician performance and using it to alter payments is becoming an agreed upon foundation for the future of Medicare. The Bill: • Creates a feedback program so CMS can use claims-based performance measures to provide individual feedback to physicians on their cost and quality performance; • Requires the Secretary to develop a broad plan for measuring and paying physicians and other providers in ways that directly reflects their performance (a “value-based purchasing” program that expands beyond hospitals) • Provides $100 million in funding for Medical Home/primary care coordination demonstration projects and gives the Secretary discretion to expand demonstration’s duration and scope • Establishes the National Quality Forum as the “gold standard” for measures to be used under the “Physician Quality Reporting Initiative, PQRI” (PQRI), but adopts the hierarchy promoted by the Consumer-Purchaser Disclosure Project that allows for other measures to be used in the absence of NQF measures. • The Bill does NOT mandate a timeframe for public reporting of physician performance

9. MIPPA expands value-purchasing and measurement beyond physicians • Expands value-based purchasing for dialysis programs (end-stage renal disease – “ESRD”) • For imaging – a high growth, high cost area of care, the bill: • Requires advanced imaging providers be accredited • Establishes two-year pilot to test the use of appropriateness criteria for imaging • But MIPPA does NOT build on existing Medicare hospital measurement and payment initiatives

10. MIPPA promotes the adoption of e-prescribing and with it improvements in the use of health information technologies • Implementation of e-prescribing has been shown to generate financial savings and reduce errors.  • The bill: • Establishes incentive payments to encourage physicians in Medicare to implement e-prescribing in 2009; • Reduces payments to those physicians who have not implemented e-prescribing by 2012 (a nice mix of “carrot and stick”); and • Incorporates provisions promoted by leading consumer groups to study privacy and security implications of e-prescribing, including data mining.

11. Support for Measuring Disparities • Secretary mandated to study and report to Congress on: • Effective approaches for ongoing data collection, measurement, and evaluation of disparities; and • Performance by race, ethnicity and gender • Secretary required to implement best approaches on measurement • Within 2 years, HHS OIG must report on Medicare providers’ compliance with CLAS Standards, with Secretary mandated to address deficiencies in this area.

12. MIPPA Shows Potential and Challenges for Value-Promoting Reform • Potential: • Agreement of system failure and need to expand coverage AND improve care • Wide bipartisan support for transparency and value-promoting reform • Concrete ideas are in discussion and “in play” • Measuring provider and treatment efficacy • Payment reform beyond the margins (promoting care coordination, episode payments) • “Value-based insurance design” • Challenges: • Continued focused opposition – both ideological and technical – to many elements of the reform agenda • Good ideas need to come from local communities and may take a LONG time to get from federal policy to local communities • Changing payment is tough – incomes, interests and patients lives at stake

13. About the Disclosure Project The Consumer-Purchaser Disclosure Project is a coalition more than 50 of the nation’s leading consumer, labor, and employer organizations that are working to advance the measurement and subsequent use of nationally standardized measures of clinical quality, efficiency, equity, and patient centeredness for health plans, hospitals, medical groups, physicians, other providers, and treatments. The Disclosure Project’s goal is to see these measures become publicly reported for the purposes of advancing the use of consumer support tools, performance-based payment reform, and quality improvement. The project is supported by financial and in-kind support of participating organizations and by financial support from the Robert Wood Johnson Foundation. Previous Discussion Forums are available at http://healthcaredisclosure.org/activities/forums/ Hospital Performance: The Expansion of Public Reporting, Performance-based Payment and Quality Improvement in Public and Private Sectors – June 24, 2008 National Performance Measurement Landscape: Basics for Consumers & Purchasers – December 10, 2007 and January 17, 2008 Medicare’s Physician Performance Agenda: Understanding Next Steps and Shaping the Future Course – February 28, 2007 Using Electronic Data to Assess Physician Quality and Efficiency – September 29, 2006 Provider Payments: How They Work, Implications for Cost & Quality, and Creating a Consumer/Purchaser Policy Agenda – July 26, 2006 Cost/Price Transparency – May 25, 2006